Tight Glucose Control No Help in PICU

Action Points

Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

This multicenter, randomized, controlled trial in the U.K. revealed no major differences in clinical outcomes among pediatric ICU patients randomized to either a standard or intensive glucose control strategy.

Be aware that a secondary analysis of noncardiac surgery patients revealed lower duration of days spent in-hospital at 1 year in the intensive glucose control group.

SAN JUAN, Puerto Rico -- Tight glycemic control won't lessen the need for mechanical ventilation in the pediatric ICU (PICU), but it may shorten overall hospital stays in the long run, researchers reported here.

In a randomized, controlled, multicenter trial, there was no difference in the primary outcome of ventilator-free days after 1 month (23.6 days with tight glycemic control versus 23.2 with conventional care), Duncan Macrae, MD, of Royal Brompton Hospital in London, and colleagues reported during a late-breaking session at the Society of Critical Care Medicine meeting here.

However, children who had their blood sugar closely monitored had a shorter overall hospital stay through 1 year, they reported.

"We did see reduced length of stay in the hospital over 12 months post-randomization, and we feel there's a need for further study to ... assess the long-term effects of the intervention," Macrae said during the presentation.

Macrae and colleagues conducted the Control of Hyperglycemia in Pediatric intensive care (CHiP) trial at 14 PICUs in the U.K., hypothesizing that tight glycemic control would increase survival and diminish the need for ventilation in these patients.

A total of 1,372 were randomized to either a conventional strategy – a target blood glucose range of 180 mg/dL to 216 mg/dL – or to tight glycemic control, with a range of 72 mg/dL to 126 mg/dL.

As expected, Macrae said, a higher proportion of tight glycemic control patients were given insulin than those on the conventional strategy (66% versus 15.8%), and mean blood glucose was lower in the tight glycemic control arm over the course of the trial.

Overall, the investigators found no difference in the number of ventilator-free days within a month of treatment, nor was there any difference when looking solely at cardiac surgery patients (25 days with tight control versus 24.7 days), which suggests that PICUs should continue with conventional management for children admitted following cardiac surgery, Macrae said.

Those results are similar to a pediatric trial in the U.S. that found no benefit for tight glucose control in the pediatric cardiac intensive care unit (CICU).

There were no differences in a host of secondary outcomes at 30 days including total PICU days, hospital days, ventilation days, organ dysfunction, or vasoactive drug days, they reported.

They noted, however, that those who had tight glucose control had less renal replacement therapy (9.2% versus 13.4%, RR 0.69, 95% CI 0.51 to 0.93).

But they also had a higher proportion of hypoglycemic episodes:

Moderate: 88% versus 20%

Severe: 51% versus 10%

And again, there were no differences in any of these parameters by cardiac surgery status, they reported.

But noncardiac surgical patients did appear to have a long-term advantage with tight control, they said. These children had fewer total hospital days over the course of a year (30.98 days versus 44.51 days).

That could save hospitals money, Macrae said. In a 30-day cost-efficacy analysis, tight control saved about $3,084 per noncardiac surgical patient. Over 1 year, the cost savings amounted to $13,091.

That could translate to a savings of about $87 million a year in the U.S. (or about $16 million in the U.K.), they calculated.

Samuel Tisherman, MD, of the University of Pittsburgh Medical Center, who moderated the session at which the findings were presented, noted that the target control range was higher than what some clinicians may be using.

"There's a big range between the control group and the tight control group," he said.

Macrae responded that the 180 to 216 mg/dL target used in the conventional arm of the study was the same control range as other studies, and that a survey of pediatric practitioners in the U.K. said that's the target at which they'd start to bring down high blood glucose.

When asked by an audience member why the researchers used ventilator-free days as the primary outcome, Macrae said a surrogate outcome that spoke of illness severity was needed since there wouldn't have been enough patients to do a mortality-based study.

The study was supported by the National Institute for Health Research in the U.K.

Reviewed by F. Perry Wilson, MD, MSCE Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

MedPageToday is a trusted and reliable source for clinical and policy coverage that directly affects the lives and practices of health care professionals.

Physicians and other healthcare professionals may also receive Continuing Medical Education (CME) and Continuing Education (CE) credits at no cost for participating in MedPage Today-hosted educational activities.